Understanding Corticosteroid Injections in Primary Care

Introduction to Corticosteroid Injections

The use of corticosteroid injections in primary care has steadily increased. These injections offer pain relief and inflammation control for various musculoskeletal conditions. As the population ages, the incidence of ailments like osteoarthritis, tendinopathy, and bursitis rises. This growing trend has made corticosteroid injections a common treatment option. However, while they provide significant benefits, there are also risks that both clinicians and patients need to consider. This article will explore the reasons for their increased use, the benefits, and the potential risks associated with corticosteroid injections.

Why is Corticosteroid Injection Use Increasing?

1. Rising Prevalence of Musculoskeletal Conditions

The demand for corticosteroid injections has recently grown. This is largely due to the higher prevalence of conditions like osteoarthritis, tendinopathy, and bursitis. These conditions are prevalent among older adults. As the global population ages, the incidence of these issues continues to increase.

2. Proven Effectiveness in Pain Management

Corticosteroid injections are known for their quick and effective pain relief. This makes them a valuable tool for patients who do not respond well to first-line treatments. These treatments might include physiotherapy or analgesics. Injections allow patients to engage in rehabilitation exercises, crucial for conditions like osteoarthritis. Here, a combination of exercise and injection therapy has proven particularly beneficial.

3. Non-Surgical Alternative

For many, corticosteroid injections serve as a means to delay or avoid surgery. This is especially true for those with comorbidities or those not suitable for surgery. These injections can act as a bridging intervention, managing symptoms while patients await surgical procedures such as joint replacements.

Benefits of Corticosteroid Injections

1. Rapid Pain Relief

Many patients find relief within days of the injection. This quick alleviation helps them regain function. It’s beneficial for individuals in manual jobs or self-employed roles who need to return to work quickly.

2. Reduction in Inflammation

Corticosteroid injections help to reduce inflammation, leading to improved mobility and function. While this is beneficial for conditions like rheumatoid arthritis and tendinopathy, there's ongoing debate regarding their long-term impact on tendon health. Some studies suggest potential negative effects over time.

3. Delaying or Avoiding Surgery

Effective symptom relief from corticosteroid injections can sometimes delay or prevent surgery. This advantage is significant for patients wanting to avoid surgery. Many patients are on long surgical waiting lists, particularly in osteoarthritis management, where injections can provide temporary relief.

Risks of Corticosteroid Injections

Like any medical intervention, corticosteroid injections come with potential side effects. Below are the common local and systemic risks, including their incidence rates where available. The primary references for these rates include Risk Management in Soft Tissue and Joint Injections from the CSP and Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications from the American Journal of Roentgenology.

Local Side Effects

Immediate Onset (Within 48 Hours)

• Post-Injection Flare: Temporary worsening of pain post-injection, commonly seen with particulate corticosteroids (Incidence: 8%).

  
  

Delayed Onset (After 48 Hours)

• Skin Hypopigmentation & Atrophy: More common with superficial injections; typically resolves in a year (Incidence: 9%).

• Soft-Tissue Calcification: Rare, but can cause increased pain.

• Infection: Uncommon but possible, especially if surgery follows soon after (Incidence: <0.001%).

• Tendon Rupture: Higher risk for tendons under stress, like the Achilles tendon (Incidence: 0.1%).

• Accelerated Osteoarthritis Progression: Some studies indicate increased joint space loss and faster radiographic progression.

• Osseous Injury: This includes insufficiency fractures, osteonecrosis, and rapid joint destruction (Incidence: 1%).

  
  

Systemic Side Effects

Immediate Onset

• Facial Flushing: More frequent in women, typically self-limiting (Incidence: 40%).

• Hypertension & Hyperglycemia: Temporary spikes in blood pressure and blood sugar (Incidence: common).

• Hypersensitivity Reactions: Rare, but can include potential anaphylaxis (Incidence: 0.3–0.5%).

• Ophthalmic Conditions: Can exacerbate glaucoma or cause chorioretinopathy.

  
  

Delayed Onset

• Osteoporosis: Repeated injections may lead to decreased bone mineral density and increased fracture risk (Incidence: Common).

• Irregular Menstruation: Can cause hormonal disturbances (Incidence: 51%, both early and delayed menstruation).

  
  

Special Considerations

• Premenopausal Women: May experience hormonal suppression and menstrual irregularities (Incidence: 51%).

• Diabetic Patients: Blood sugar levels can spike, necessitating careful monitoring (Incidence: Common).

• Athletes: Increased risk of tendon weakening and adrenal insufficiency; high-impact activities are best avoided after injections.

• Paediatric Patients: There is limited data available, but the potential for significant side effects such as Cushing’s syndrome exists (Incidence: 2.6%).

• Patients on Anticoagulants: The risk of bleeding remains low, and most guidelines recommend not discontinuing anticoagulation therapy (Incidence: Low).

• Patients on Ritonavir: Face a high risk of adrenal insufficiency due to drug interactions.

  
  

Conclusion

Corticosteroid injections play a valuable role in primary care musculoskeletal management. They offer effective short-term pain relief. However, it is critically important to weigh the risks and benefits carefully. Shared decision-making is essential. Patients must be informed about the potential side effects. Injections should rarely stand alone as a treatment. They should instead be part of a comprehensive management plan, which includes exercise, physiotherapy, and lifestyle modifications.

For further insights into musculoskeletal management, check out Andy's work here: https://blog.andyhubbert.co.uk.

References

Cleveland Clinic (no date) Cortisone Shots: How They Work and Side Effects, Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/treatments/cortisone-shots-steroid-injections (Accessed: 31 January 2025).

Dr Graeme Wilkes (N.D.) Risk Management in Soft Tissue and Joint Injections. Available at: https://www.csp.org.uk/system/files/documents/2019-04/risk_management_in_soft_tisse_and_joint_injections_-_presentation.pdf (Accessed: 31 January 2025).

Foster, Z.J. et al. (2015) ‘Corticosteroid Injections for Common Musculoskeletal Conditions’, American Family Physician, 92(8), pp. 694–699. Available at: https://www.aafp.org/pubs/afp/issues/2015/1015/p694.html (Accessed: 31 January 2025).

Holt, T.A. et al. (2013) ‘Corticosteroid injection for shoulder pain: single-blind randomized pilot trial in primary care’, Trials, 14(1), p. 425. Available at: https://doi.org/10.1186/1745-6215-14-425.

Kamel, S.I., Rosas, H.G. and Gorbachova, T. (2024) ‘Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications’, American Journal of Roentgenology, 222(3), p. e2330458. Available at: https://doi.org/10.2214/AJR.23.30458.

Kjeken, I. and Sundin, U. (2023) ‘Management of carpal tunnel syndrome in primary care’, Rheumatology, 62(2), pp. 495–496. Available at: https://doi.org/10.1093/rheumatology/keac396.

Moore, A.J. et al. (2024) ‘Intra-articular corticosteroid injections for osteoarthritis: A qualitative study of patients’ and clinicians’ experiences’, PLOS ONE. Edited by D. Tarantino, 19(10), p. e0311668. Available at: https://doi.org/10.1371/journal.pone.0311668.